MEDICARE: DENTAL SPECIALTY CENTER OF FT. MYERS, PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	1223E0200X	Endodontics
2	1223P0300X	Periodontics
3	1223S0112X	Oral and Maxillofacial Surgery (Dentist)
4	122300000X	Dentist

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1659616993
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DENTAL SPECIALTY CENTER OF FT. MYERS, PA

Provider Business Mailing Address
First Line	:	13195 SW 134 ST
Second Line	:	2ND FLOOR
City	:	MIAMI
State	:	FL
Zip	:	33186
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	7011 CYPRESS TER
Second Line	:	SUITE 101
City	:	FORT MYERS
State	:	FL
Zip	:	33907-8800
Country	:	US
Telephone Number	:	239-433-3075
Fax Number	:

Authorized Official
Title or Position	:	PROVIDER RELATIONS SPECIALIST
Name	:	STEPHANIE GOMEZ
Credential	:
Telephone Number	:	305-274-2499

Provider Enumeration Date	:	11/27/2012
Last Update Date	:	08/06/2014

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